Care Review Clinician, Prior Authorization RMOTE in New York
2 weeks ago
Job Summary
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
This position will support our Senior Whole Health business. Senior Whole Health by Molina is a Managed Long-Term Care (MLTC), and Medicaid Advantage (MAP) plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid and Medicare. We are looking for Registered Nurse Care Review Clinicians with Prior Authorization experience. Experience with Utilization Management (UM) is highly preferred.
KNOWLEDGE/SKILLS/ABILITIES
Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
Processes requests within required timelines.
Refers appropriate prior authorization requests to Medical Directors.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Molina Care Model
Adheres to UM policies and procedures.
Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
JOB QUALIFICATIONS
Required Education
Any of the following:
Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR a bachelor’s or master’s degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only).
Required Experience
1-3 years of hospital or medical clinic experience.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care Review Clinicians only).
Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
Preferred Experience
3-5 years clinical practice with managed care, hospital nursing or utilization management experience.
Preferred Experience
UM experience highly preferred
Proficient computer experience
Required License, Certification, Association
Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Pay Range: $21.82 - $51.06 / HOURLY
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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